Private Health Insurance Decision Reference 2022-0357

• Case Outcome: Rejected
• Subject Matter: Private Health Insurance
• Reference: 2022-0357
• Date: 01 November 2022
• Finantial Sector: Insurance
• Conducts Complained Of: Claim handling delays or issues,Rejection of claim - pre-existing condition, Rejection of claim - waiting periods apply

Decision Ref:

2022-0357

Sector:

Insurance

Product / Service:

Private Health Insurance

Conduct(s) complained of:

Claim handling delays or issues

Rejection of claim - pre-existing condition

Rejection of claim - waiting periods apply

Outcome:

Rejected

LEGALLY BINDING DECISION OF THE FINANCIAL SERVICES AND PENSIONS OMBUDSMAN

This complaint relates to the rejection of a claim made under a health insurance policy held

with the Provider.

The Complainant’s Case

The Complainant holds a health insurance policy with the Provider, incepted on 31 October

2017. The Complainant required two medical procedures in 2019, one in January 2019 in

Hospital A and one in August 2019 in Hospital B. The medical procedures concerned the

insertion and removal of a heart monitor, and a cardiac ablation.

The Complainant states that she spoke to the Provider before undertaking the procedures

and was informed that she would be covered once she completed a 26-week standard

waiting period. However, when she submitted a claim to the Provider for the cost of the two

procedures, her claim was declined on the basis that the treatment and procedures were

for a pre-existing medical condition, and cover was therefore subject to a five-year waiting

period.

The Complainant submits two letters from consultant cardiologists, including the doctor

who completed the ablation procedure, to state that she did not have a pre-existing

condition.